Confidential 


FOR  OFFICIAL  USE  ONLY 


MEMORANDUM  ON 


GAS  POISONING  IN  WARFARE 

WITH  NOTES  ON  ITS 

PATHOLOGY  AND  TREATMENT 


NOTE. — This  Memorandum  has  been  drawn  up  by  a  Committee  of  Con- 
sultant Physicians  and  Physiologists  for  the  information  of  Medical  Officers. 
IT  IS  TO  BE  TREATED  AS  CONFIDENTIAL,  AND  SHOULD  ON  NO 
ACCOUNT  BE  TAKEN  INTO  THE  TRENCHES. 


EblTED  AT  THE  ARMY  WAR  COLLEGE 
MAY,  1917 


WASHINGTON 

GOVERNMENT  PRINTING  OFFICE 
1917 


Confidential 

FOR  OFFICIAL  USE  ONLY 

MEMORANDUM  ON 

GAS  POISONING  IN  WARFARE 

WITH  NOTES  ON  ITS 

PATHOLOGY  AND  TREATMENT 


NOTE. — This  Memorandum  has  been  drawn  up  by  a  Committee  of  Con- 
sultant Physicians  and  Physiologists  for  the  information  of  Medical  Officers. 
IT  IS  TO  BE  TREATED  AS  CONFIDENTIAL,  AND  SHOULD  ON  NO 
ACCOUNT  BE  TAKEN  INTO  THE  TRENCHES. 


EDITED  AT   THE  ARMY  WAR   COLLEGE 
MAY,  1917 


WASHINGTON 

GOVERNMENT  PRINTING  OFFICE 
1917 


uz. 


WAR   DEPARTMENT, 

Document  No.  593. 
Office  of  The  Adjutant  General. 


WAR  DEPARTMENT, 

WASHINGTON,  May  17,  1917. 

The  following  Memorandum  on  Gas  Poisoning  in  Warfare,  with 
notes  on  its  pathology  and  treatment,  is  published  for  the  informa- 
tion and  guidance  of  all  concerned. 
[2599035,  A.  G.  0.] 

BY   ORDER   OP  THE    SECRETARY  OP  WAR  I 

TASKER  H.  BLISS, 
Major  General,  Acting  Chief  of  Staff. 

OFFICIAL: 

H.  P.  McCAIN, 

The  Adjutant  General. 

(3) 


664381 


GENERAL  CONSIDERATIONS. 


The  employment  of  poisonous  gases  as  a  means  of  offensive  warfare 
has  made  it  imperative  that  medical  officers  should  have  some  knowl- 
edge of  the  action  of  the  various  gases  that  are  likely  to  be  met  with 
and  of  rational  lines  of  treatment  which  may  be  adopted  in  cases  of 
gas  poisoning. 

Poisonous  gases  have  been  used  in  warfare  with  the  intention  of 
putting  men  out  of  action,  hampering  Artillery,  preventing  supports 
from  advancing,  and  inspiring  general  terror,  so  that  an  advance  may 
be  made  with  a  minimum  of  opposition  and  some  military  advantage 
secured.  Apart  from  any  question  of  an  advance,  poisonous  gases 
have  been  used  merely  as  a  means  of  causing  a  certain  number  of 
casualties  on  the  opposing  side  and  of  inspiring  terror. 

Besides  this  deliberate  use  of  gas  for  offensive  purposes,  poisonous 
gases  are  liable  to  be  encountered  under  other  circumstances— e.  g., 
during  mining  operations,  or  as  the  result  of  the  imperfect  detonation 
or  burning  of  explosives. 

THE  MODE  OP  ACTION  OP  POISONOUS  GASES. 

Poisonous  gases  that  are  liable  to  be  met  with  can  be  grouped 
roughly,  according  to  the  main  physiological  action  that  they  pro- 
duce on  the  animal  body.  It  must,  however,  be  clearly  understood 
that  it  is  impossible  to  draw  absolute  distinctions,  since  many  of  the 
gases  partake  of  the  characters  of  at  least  two  of  the  groups. 

I.    GASES    WHICH   ACT   AS   LUNG   IRRITANTS. 

The  main  characteristic  of  gases  of  this  group  is  that  they  cause  the 
onset  of  a  profuse  pulmonary  edema.  The  accumulation  of  fluid 
in  the  lungs  interferes  with  the  respiratory  exchange,  causing  intense 
cyanosis  and  death  by  asphyxia.  In  addition  to  this  these  gases  are 
irritating  to  the  respiratory  passages,  some  of  them  intensely  so, 
causing  great  pain  and  discomfort  in  the  chest.  They  may  also  cause 
marked  irritation  of  the  eyes  and  lachrymation.  In  some  cases 
circulatory  failure  is  a  very  marked  feature,  and  the  cyanosis  may 
then  give  place  to  the  leaden  pallor  of  collapse.  With  some  gases  of 
this  class  mild  poisoning  may  lead  to  a  condition  somewhat  akin  to 
asthma. 

(5) 


6 

Type  1 — Chlorine. — A  concentration  of  1  in  100,000  can  be  respired 
for  a  considerable  time,  though  this  may  give  rise  to  subsequent 
bronchitis. 

A  concentration  cf  1  in  10,000  is  barely  respirable  by  man  and 
experimentally  in  net  borne  for  more  than  two  or  three  breaths.  It 
produces  irritc,tion  o-*  the  ey^s,  epasm  of  the  glottis,  a  feeling  of  chok- 
ing, and  severe  cough.  If  the  inhalation  is  continued,  the  struggle 
for  breath  becomes  more  acute  and  the  man  will  be  rapidly  in- 
capacitated. In  such  a  concentration  edema  of  the  lungs  com- 
mences very  soon  and  develops  steadily. 

Type  2 — Nitrous  fumes,  i.  e.,  nitric  oxide  and  nitrogen  peroxide. — 
Sensory  irritation  of  the  eyes  and  upper  respiratory  passages  is  slight 
as  a  rule,  and  passes  off  in  a  short  time  after  leaving  the  dangerous 
atmosphere.  For  some  time  after  this  the  man  may  feel  perfectly 
well  and  go  about  his  ordinary  business,  but  after  the  lapse  of  a  few 
hours  acute  symptoms  of  pulmonary  edema  suddenly  come  on  and 
progress  with  alarming  rapidity. 

In  contradistinction  to  chlorine  poisoning,  there  is,  therefore,  a 
very  definite  delay  before  the  onset  of  pulmonary  edema,  and  the 
slightness  of  the  symptoms  shown  by  the  man  while  he  is  in  the 
dangerous  atmosphere  would  not  naturally  lead  one  to  anticipate 
the  disastrous  effects  which  may  develop  later. 

Type  3 — Phosgene. — In  certain  characteristics  this  gas  holds  an 
intermediate  position  between  chlorine  and  nitrous  fumes.  Though 
it  is  a  more  intense  eye  irritant  than  chlorine,  it  is  not  so  immedi- 
ately irritant  to  the  upper  respiratory  passages  and  there  is  some 
delay  before  the  onset  of  pulmonary  edema.  Circulatory  failure 
is  apt  to  be  a  prominent  feature  and  cases  exhibiting  a  leaden  pallor 
and  collapse  are  the  rule  rather  than  the  exception.  Phosgene 
incapacitates  a  man  more  slowly  than  chlorine  but  is  a  more  serious 
poison. 

II.    GASES    WHICH   ACT   AS    EYE   IRRITANTS    OR  LACHRYMATORS. 

The  main  characteristics  of  this  group  of  gases  are  that  in  exceed- 
ingly small  concentrations  they  exert  an  intense  irritant  effect  on 
the  eyes  and  cause  so  profuse  a  flow  of  tears  and  often  so  much  pain 
that  vision  may  be  impossible.  In  stronger  concentration  they  may 
also  act  as  acute  lung  irritants. 

Type — Benzyl  bromide. — A  very  minute  concentration  causes 
marked  lachrymation.  A  high  concentration,  when  the  eyes  are 
protected,  rapidly  causes  respiratory  discomfort,  irritation  of  the 
throat,  and  nausea. 


III.  GASES  WHICH  ACT  AS  DIRECT  POISONS  OF  THE  NERVOUS  SYSTEM. 

The  characteristics  of  this  group  of  gases  are  that  in  sufficient  con- 
centration they  act  on  the  central  nervous  system  with  great  rapidity, 
causing  a  cessation  and  finally  a  total  abolition  of  its  functions. 
Some  of  these  gases  cause  delayed  pulmonary  edema  in  cases  which 
have  not  succumbed  rapidly  from  the  effects  on  the  central  nervous 
system. 

Type — Hydrocyanic  acid. — Minute  concentrations  are  practically 
innocuous.  High  concentrations  cause  immediate  unconsciousness 
and  death  in  a  few  seconds. 

Animals  if  taken  out  of  the  poisonous  atmosphere  as  soon  as  they 
have  fallen  down  paralyzed,  may  recover  perfectly  in  a  short  time. 

IV.  GASES    WHICH    ACT    BY    INTERFERING    WITH    THE    RESPIRATORY 

PROPERTIES    OF   THE    BLOOD. 

Under  this  heading  may  be  grouped  cases  which  cause  destruction 
of  red  cells,  alter  the  hemoglobin,  or  combine  with  the  hemoglobin 
to  the  exclusion  of  oxygen,  so  that  severe  symptoms  arise  because 
the  oxygen-carrying  power  of  the  blood  is  interfered  with.  Certain 
cases  may,  for  instance,  lead  to  destruction  of  red  cells,  accom- 
panied by  hemoglobinuria  or  jaundice.  Again,  nitrous  fumes  in 
strong  concentration  may  cause  the  alteration  of  hemoglobin  into 
methemoglobin  in  addition  to  producing  the  intense  irritation  of  the 
lungs  mentioned  above. 

Carbon  monoxide. — This  gas  owes  its  poisonous  action  to  the  fact 
that  it  combines  with  hemoglobin  to  form  a  dissociable  compound 
and  thereby  takes  the  place  of  oxygen.  Carbon  monoxide  has  about 
300  times  the  affinity  for  hemoglobin  that  oxygen  has.  If  therefore 
a  small  proportion  of  carbon  monoxide  is  present  in  the  air  breathed, 
the  hemoglobin  in  the  body  will  divide  itself  between  the  two  gases, 
the  final  partition  being  determined  by  the  relative  concentration 
of  the  two  gases.  The  oxygen-carrying  power  of  the  blood  is  pro- 
gressively diminished  as  the  hemoglobin  becomes  more  and  more 
saturated  with  carbon  monoxide,  and  symptoms  arise  owing  to  the 
interference  with  the  oxygen  supply  to  the  tissues  from  this  cause. 

CIRCUMSTANCES    UNDER   WHICH   GAS   POISONING    MAY   BE    MET   WITH 
IN    WARFARE. 

Some  poisonous  gases  of  the  foregoing  groups  are  well  adapted  for 
use  as  offensive  agents  in  warfare,  while  others  are  unsuitable  owing 
to  various  causes,  such  as  difficulty  of  manufacture  or  of  storage, 
chemical  instability,  limited  toxicity  save  in  high  concentrations 


8 

or  after  prolonged  exposure,  or  insufficient  density.  Though  the 
acute  lung  irritants  as  a  whole  must  be  classed  among  the  more 
powerful  methods  of  destruction,  nitrous  fumes  do  not  lend  them- 
selves to  deliberate  offensive  use.  They  may  be  met  with  during 
warfare  accidentally  under  certain  circumstances.  Carbon  mon- 
oxide, too,  is  not  adapted  to  offensive  use,  though  it  may  prove  a 
very  serious  factor  indeed  when  met  with  during  mining  operations. 

THE    USE    OF   GAS   FOR   OFFENSIVE    PURPOSES. 

(a)  Cloud  gas. — The  rate  at  which  the  cloud  gas  is  carried  over  the 
ground  intervening  between  the  trenches  of  the  two  opposing  forces 
depends  entirely  on  the  velocity  of  the  wind.  With  winds  at  the 
rates  of  3,  9,  and  15  miles  per  hour,  the  gas  cloud  would  move 
forward  at  the  rate  of  90,  270,  and  450  yards  per  minute,  respectively; 
and  with  a  wind  of  9  miles  per  hour,  the  distance  of  100  yards  would 
be  covered  in  about  20  seconds.  These  figures  indicate  how  short 
may  be  the  time  available  for  warning  men  in  the  front  trenches  of 
the  commencement  of  a  cloud  gas  attack  and  emphasize  the  extreme 
importance  of  training  troops  thoroughly  in  the  use  of  protective 
devices. 

(6)  Gas  shells  and  gas  bombs. — In  this  case  the  poisonous  substance 
is  contained  in  liquid  form  in  the  shell  or  bomb  and  is  converted  into 
a  cloud  of  vapor  on  the  explosion .  As  a  rule  these  shells  are  employed 
to  produce  a  toxic  effect  at  a  distance  over  a  limited  area  and  are 
most  frequently  used  against  batteries,  or  in  the  form  of  a  "tir  de 
barrage"  to  interfere  with  the  movements  of  supports  during  an 
engagement. 

The  commonest  gas  shell  used  by  the  Germans  contains  the 
lachrymators,  benzyl,  and  xylyl  bromides,  but  shells  containing 
acute  lung  irritants  have  also  been  employed. 

A  cloud  gas  attack  necessitates  a  favorable  wind  blowing  toward 
the  enemy's  position,  but  gas  shells  can  be  used  even  if  the  wind 
is  blowing  toward  the  user,  since  if  the  gas  is  blown  back,  it  will 
have  been  so  diluted  with  air  as  to  be  harmless  to  him.  A  cloud  gas 
attack  may  be  preceded  or  accompanied  by  a  gas  shell  attack,  and 
gas  shells  of  different  forms  may  be  fired  not  only  on  points  behind 
the  trenches  but  also  on  the  front  line  and  support  trenches  as  well. 

Medical  officers  must,  therefore,  remember  that  more  than  one 
method  may  be  used  at  the  same  time  during  a  gas  attack  and  that 
different  chemical  substances  may  be  simultaneously  employed. 
They  must  in  consequence  be  on  the  watch  for  differences  in  the 
symptoms  presented  by  gassed  cases  so  that  they  may  report  the 
facts  to  headquarters  and  adopt  suitable  treatment. 


9 


CIRCUMSTANCES  UNDER  WHICH  POISONOUS  GASES  OTHER  THAN 
THOSE  USED  DELIBERATELY  FOR  OFFENSIVE  PURPOSES  ARE 
LIABLE  TO  BE  ENCOUNTERED. 

(a)  Mine  gases. — During  mining  operations^the  most  dangerous  gas 
met  with  is  carbon  monoxide.  This  arises  from  the  imperfect 
detonation  or  combustion  of  the  explosives  used  for  charging  the 
mine  or  for  blasting.  The  galleries  may  be  flooded  with  the  gas 
after  the  explosion  of  either  our  own  or  a  hostile  mine,  as  the  result 
of  the  explosion  of  a  hostile  camouflet  designed  to  blow  in  our  gal- 
leries, or  as  the  result  of  the  explosion  or  burning  of  a  blasting  charge. 
The  gas  is  liable  to  be  driven  into  the  ground  disturbed  by  the 
explosion  and  to  come  welling  out  later,  especially  if  the  barometer 
commences  to  fall  after  the  explosion,  or  it  may  be  met  with  in  the 
form  of  pockets  of  gas  when  new  galleries  are  driven  through  ground 
disturbed  by  a  previous  explosion.  Carbon  monoxide  has  even 
been  known  to  be  driven  out  of  the  shafts  into  the  adjacent  trenches 
after  the  explosion  of  a  mine. 

Besides  carbon  monoxide,  nitrous  fumes  may  arise  if  a  charge 
does  not  explode  properly,  and  especially  if  it  burns  instead  of 
exploding.  Nitrous  fumes  are  quickly  absorbed  by  moist  ground, 
and  so  cases  of  nitrous  fumes  poisoning  are  seldom  met  with  unless 
men  are  exposed  to  the  fumes  immediately  after  the  explosion  or 
the  burning  of  the  charge. 

(6)  Fumes  from  high-explosive  shells. — Nitrous  fumes  have  so  far 
given  rise  to  no  cases  of  poisoning  after  the  explosion  of  high-explosive 
shells.  Cases  of  carbon  monoxide  poisoning  have  been  known  to 
arise  under  special  circumstances — e.  g.,  when  a  shell  has  penetrated 
into  a  deep  dugout  before  bursting.  Such  cases  are,  however,  un- 
likely to  arise  unless  the  shell  explodes  in  a  confined  space,  since 
either  a  high  concentration  or  a  prolonged  exposure  is  required  for  the 
production  of  symptoms. 

(c)  Fumes  from  the  firing  of  guns. — In  closed  machine-gun  emplace- 
ments, owing  to  the  blowback  from  the  gun,  enough  CO  sometimes 
gets  into  the  air  to  give  rise  to  symptoms.    Symptoms  of  CO  poisoning 
are  also  sometimes  caused  in  gun  pits  owing  to  the  blowback  on  open- 
ing the  breech  when  certain  forms  of  powder  are  used. 

(d)  Burning  ofnitro  explosives. — If  nitro  explosives  are  accidently 
set  on  fire  and  continue  to  burn  without  explosion,  there  is  great 
danger  of  poisoning  from  nitrous  fumes.    Carbon  monoxide  poisoning 
may  also  occur. 

99456-1? 2 


10 

(e)  Burning  buildings. — It  must  be  remembered  that  when  com- 
bustion takes  place  in  a  limited  supply  of  air,  as  in  the  interior  of  a 
burning  building,  there  is  a  considerable  risk  of  carbon  monoxide 
poisoning. 

(/)  Warming  of  billets. — A  burning  coke  brazier  in  a  small,  ill- 
ventilated  billet  is  very  likely  to  give  rise  to  cases  of  carbon  monoxide 
poisoning. 

POISONING  BY  GAS  CLOUD. 

The  gas  used  by  the  Germans  in  attacks  made  on  the  English 
trenches  by  poisonous  clouds  drifting  forward  on  the  wind  was  in  the 
early  summer  of  1915  chiefly,  if  not  solely,  chlorine.  Later  it 
became  apparent  from  the  change  of  symptoms  in  casualties  that  a 
different  form  of  gas  was  being  employed  and  this  is  believed,  though 
not  proved,  to  be  a  mixture  of  chlorine  with  varying  proportions  of 
carbonyl  chloride  or  phosgene  gas.  It  is,  therefore,  necessary  to 
describe  separately  the  action  of  each  type  of  cloud  gas. 

CLOUD  GAS   OF  SUMMER   OP   1915. 

The  following  account  of  the  pathological  changes  is  based  entirely 
upon  observations  made  on  men  injured  by  German  cloud  gas  in  1915, 
and  these  observations  coincide  with  what  has  been  noted  in  labora- 
tory experiments  with  chlorine.  The  effects  may  be  classified  under 
the  following  headings: 

Irritation  and  inflammation  of  the  respiratory  tract. 

Interference  with  the  circulation. 

General  toxic  effects. 

RESPIRATORY   TRACT. 

Chlorine  is  very  irritant.  Sensory  nerves  are  violently  stimulated, 
causing  immediate  pain  and  uncontrollable  reflex  movements,  such 
as  coughing  or  spasmodic  gasping,  which  interfere  with  respiration. 
Lachrymation  is  relatively  slight.  A  heavy  concentration  of  the  gas 
seems  almost  irrespirable,  but  the  spasmodic  check  to  breathing 
ultimately  gives  way,  and  no  case  of  death  from  asphyxia  immedia- 
tely upon  exposure  to  the  gas  has  been  proved  to  have  occurred  in 
the  English  lines.  Breathing  continues,  but  it  is  of  a  spasmodic 
character  and  accompanied  by  violent  coughing  which,  as  will  be 
described  later,  has  a  very  harmful  effect  on  the  lungs. 

The  irritation  of  the  sensory  nerves,  however,  is  not  the  fatal  factor. 
An  inflammatory  reaction,  with  congestion  of  the  vessels,  edema  of 
the  tissues  and  an  abundant  discharge  of  serous  effusion  through  the 


11 

dying  epithelium  occurs  all  the  way  down  the  respiratory  tract. 
This  begins  at  the  back  of  the  throat;  the  larynx,  with  its  resistant 
epithelium,  escapes  injury,  but  the  damage  to  the  surface  tissues 
increases  progressively  down  the  trachea,  the  bronchi  and  their  finer 
branchings,  and  ultimately  attains  its  maximum  in  the  air  sacs. 
The  bronchioles  are  rapidly  filled  with  a  serous  exudate  which  passes 
up  into  the  trachea  and  is  coughed  out. 

A  universal  obstruction  in  this  way  of  the  bronchioles  alone  would 
suffice  to  cause  death  by  simple  blockage  of  the  airway  and  asphyxia. 
But  the  injury  is  not  confined  to  the  bronchial  tree,  and  probably  the 
effusion  in  the  tubes  alone  is  not  dense  enough  to  hinder  the  passage 
of  some  air  up  and  down,  though  even  this  thin  fluid  may  constitute 
a  very  serious  mechanical  obstruction  when  it  is  churned  up  into  a 
continuous  foam  by  violent  respiratory  efforts.  At  first  there  may  be 
so  much  spasmodic  contraction  of  the  muscles  of  the  smaller  bron- 
chioles that  the  gas  is  denied  access  to  many  areas  of  the  lungs. 
Sooner  or  later  these  relax,  and  the  irritant  vapors  then  destroy  the 
pulmonary  epithelium,  while  the  air  sacs  rapidly, fill  up  with  inflam- 
matory exudate  and  become  utterly  useless  for  the  purpose  of  respira- 
tory exchange.  The  edematous  effusion  must  ultimately  compress 
the  capillaries  and  cause  great  hindrance  to  the  flow  of  blood  through 
the  lungs.  The  irritation  spreads  so  widely  that  a  blood-stained 
serous  effusion  soon  accumulates  in  the  pleural  cavity,  but  this  is 
never  so  abundant  as  to  require  aspiration. 

In  addition  to  this  inflammatory  edema,  which  chokes  the  circula- 
tion and  prevents  gaseous  exchange,  there  is  often  some  actual 
damage  to  the  structure  of  the  lungs.  The  violent  coughing  and 
inspiratory  efforts  which  may  result  from  inhalation  of  the  gas  may 
be  so  forcible  that  the  partitions  between  the  alveoli  are  torn  and 
air  may  even  burst  its  way  out  into  the  areolar  tissue  and  escape 
along  the  hilum  of  the  lung  and  up  into  the  subcutaneous  tissues 
of  the  neck.  Such  disruptive  emphysema  adds  at  once  to  the 
disability  of  the  sufferer,  since  it  throws  out  of  action  that  part  of 
the  lung  which  is  not  yet  submerged  in  the  rising  flood  of  edema  fluid, 
and  it  may  lead  to  permanent  shortness  of  breath  if  the  man  survives. 

There  are,  therefore,  four  factors  which  develop  in  rapid  suc- 
cession and  prevent  exchange  of  respiratory  gases  through  the  lungs: 

(1)  Narrowing  of  the  bronchioles  by  spasmodic  contraction  of 
muscles  in  their  walls. 

(2)  Disruptive  emphysema. 

(3)  Obstruction  of  the  bronchial  tubes  by  exudate. 


12 

(4)  Flooding  of  the  pulmonary  air  sacs  by  serous  effusion  into 
them. 

The  result  of  these  changes  in  the  lungs,  of  which  (3)  and  (4)  are 
the  most  important,  is  that  the  intake  of  oxygen  and  the  elimination 
of  carbon  dioxide  are  seriously  interfered  with,  and  the  man  passes 
into  a  state  of  asphyxial  cyanosis  in  which  mental  failure  and 
unconsciousness  may  rapidly  supervene.  During  this  state  the 
breathing  is  labored,  rapid,  and  interrupted  by  spasmodic  bouts  of 
coughing.  The  blue  color  of  the  face  shows  the  urgent  need  for 
oxygen,  and  every  muscular  effort  made  by  the  body  and  by  the 
heart  increases  that  need.  Coughing  is  helpful  in  so  far  as  it  may 
dislodge  exudate  from  the  bronchi,  but  the  violent  effort  is  prodigal 
of  such  oxygen  as  can  be  supplied  and  it  tends  to  increase  the  dis- 
ruptive emphysema.  The  increased  respiration  is  caused  both  by 
the  accumulation  of  carbon  dioxide  and  by  the  want  of  oxygen 
and  not  by  the  absorption  of  any  poisonous  substance  from  the  gas. 
In  itself,  this  increased  breathing  does  no  harm  and  it  helps  in 
eliminating  C02  and  increasing  the  intake  of  oxygen  which  are  the 
chief  needs  of  the  moment. 

Interference  with  circulation. — The  ordinary  phenomena  in  as- 
phyxia of  mechanical  origin  are  that  the  blood  pressure  rises  and 
that  the  heart  soon  loses  its  full  driving  power  because  its  muscle 
can  not  maintain  this  increased  effort  when  it  is  working  with  a 
scanty  supply  of  oxygen.  Consequently  the  pulse  rate  quickens, 
the  right  heart  dilates  and  the  blood  tends  to  be  pooled  up  behind 
it  in  the  great  veins.  If  this  failure  proceeds  apace,  a  patient  who 
at  the  beginning  showed  congestive  cyanosis  of  the  face  with  a  full 
pulse  will  gradually  assume  a  gray  pallor  while  the  pulse  accele- 
rates and  falls  off  in  power.  These  changes  are  present  in  cloud 
gas  poisoning  and  they  are  augmented  by  the  edema  of  the  lungs, 
which  directly  obstructs  the  pulmonary  circulation  and  causes  an 
earlier  failure  of  the  right  side  of  the  heart. 

If  the  patient  during  this  critical  time  tries  to  carry  on  his 
work  and  remain  standing,  he  will  use  up  still  more  rapidly  the 
little  oxygen  that  he  is  receiving,  extra  work  will  be  loaded  on  to 
a  heart  which  is  already  overstrained  and  the  circulation  will  be 
likely  to  fail  still  more  speedily  on  account  of  the  difficulty  of 
maintaining  compensation  in  the  upright  posture. 

There  is  no  interference  with  the  respiratory  properties  of  the 
blood  which  can  at  once  take  up  any  oxygen  that  reaches  it  through 
the  lungs. 


13 

General  toxic  effects.— Experiments  indicate  that  chlorine  is  not 
absorbed  from  the  lungs  and  that  the  effects  produced  by  this  gas 
are  only  a  direct  and  local  inflammation  with  secondary  results 
which  are  either  of  a  mechanical  nature  or  caused  by  oxygen  want, 
or  due  to  a  nervous  reflex  from  the  seat  of  injury.  Changes  of  a 
general  nature  do  undeniably  appear  in  the  nervous,  circulatory, 
alimentary,  and  renal  systems  of  a  man  who  has  been  poisoned  by 
cloud  gas,  but  these  are  probably  the  result  of  the  asphyxia  rather 
than  of  the  direct  action  of  the  gas.  Thus  in  the  mild  cases  there 
is  a  sense  of  fatigue  and  of  being  altogether  done  up,  and  in  the 
serious  cases  even  unconsciousness,  but  these  features  are  not  in 
excess  of  what  may  result  from  oxygen  want.  The  retching  and 
vomiting  that  generally  occur  in  the  first  stages  of  poisoning  may  be 
due  only  to  direct  irritation  of  the  back  of  the  throat  and  of  the 
stomach  by  the  gas,  or  may  be  the  direct  sequence  of  violent  bouts 
of  coughing;,  while  the  diarrhea,  which  sometimes  is  an  early  feature, 
may  be  that  of  emotion. 

Microscopic  examination  of  the  kidneys  in  death,  a  few  days  after 
gassing,  reveals  very  definite  inflammatory  and  destructive  changes, 
and  such  kidneys  may  be  swollen  and  enlarged  as  though  with  a 
parenchymatous  nephritis.  This  change,  however  produced,  rarely 
leads  to  any  clinical  feature  of  renal  trouble.  In  the  first  few  days 
the  urine  contains  neither  sugar  nor  albumen  nor  many  casts,  and 
it  is  very  unusual  for  albuminuria  to  develop  later. 

The  circulation  may  fail  with  unexpected  rapidity  and  the  patient 
soon  present  the  aspect  of  a  leaden  gray  cyanosis.  But  in  general 
terms  the  clinical  picture  with  chlorine  may  be  summed  up  as  that 
of  a  man  suffering  from  intense  irritation  of  the  respiratory  tract 
and  dying  by  asphyxia  from  the  fluid  that  has  drowned  his  lungs. 
It  does  not  suggest  a  deeper  toxic  action. 

Post-mortem  findings. — In  a  case  of  death  at  24  hours  after  gas- 
sing, the  trachea  and  bronchi  are  purple  red  and  congested,  while 
a  thin  serous  exudate  wells  up  into  them  from  the  lungs.  The 
latter  organs  are  heavy  and  edematous,  while  aerated  islets  of 
emphysematous  overdistention  alternate  with  depressed  purple 
patches  of  collapse.  On  section,  serous  fluid  drips  abundantly 
from  the  lung  tissue.  Air  that  has  escaped  from  ruptured  vesicles 
is  seen  in  chains  of  bubbles  on  the  surface  of  the  lungs,  along  the 
interlobar  fissure  and  even  penetrating  the  tissues  of  the  medias- 
tinum. In  some  of  the  earliest  cases  the  most  intense  disruptive 
emphysema  was  observed,  destroying  the  air  sacs  and  interfering 
with  the  circulation  in  their  walls. 


14 

fetecmal  hemorrhages  appear  on  the  surface  of  the  lungs,  on 
the  heart,  and  also  on  the  inner  surface  of  the  stomach.  All  the 
veins  are  greatly  distended  and  the  abdominal  viscera  are  en- 
gorged with  dark  blood  that  clots  very  early  after  death.  The 
heart  itself  may  fail  to  show  right-sided  dilatation,  for  this  does  not 
of  necessity  appear  post  mortem  in  cases  of  asphyxial  death. 

If  the  man  succumbs  at  a  later  date,  inflammatory  complica- 
tions appear  in  the  lungs.  There  is  superficial  pleurisy,  scattered 
broncho-pneumonia,  and  a  purulent  secretion  in  the  bronchi.  The 
serous  exudate  will  then  be  found  to  have  disappeared  and  no  fluid 
drips  from  the  cut  surface  of  the  lungs. 

CLOUD   GAS   OF  1916. 

The  symptoms  tend  to  differ  from  those  produced  by  chlorine  in 
three  main  details. 

(1)  Subjective  respiratory  irritation  is  much  less  in  evidence. 
The  men  do  not  suffer  with  such  violent  coughing  when  first  ex- 
posed to  the  gas.    There  is  consequently  less  disruptive  emphy- 
sema of  the  lungs,  and  subcutaneous  emphysema  of  the  neck  is 
rare,  while  post-mortem  examination  in  early  cases  often  fails  to 
find  anything  more  than  a  little  escape  of  air  along  the  inter  lobar 
fissure. 

(2)  The  poisonous  effects  may  appear  speedily  with  cyanotic 
asphyxia,  but  sometimes  they  are  more  insidious  in  their  onset.    A 
man  may  feel  able  to  carry  on  his  work  for  an  hour  or  two  with 
only  trivial  symptoms;  then  he  rapidly  becomes  worse  and  passes 
into  a  state  of  grayish  white  collapse,  with  progressive  edema  of 
the  lungs  that  may  soon  be  fatal.     It  has  even  been  reported  from 
the  trenches  that  men  who  have  passed  through  a  gas  attack  and 
seemed  to  have  suffered  but  slightly  have   died   abruptly  some 
hours  later  upon  attempting  some  bodily  effort. 

(3)  Features  suggestive  of  general  collapse  are  more  in  evidence. 
There  is  a  much  greater  tendency  to  circulatory  failure.    Many  of 
the  cases  that  die  on  the  first  day  show  a  leaden  gray  tint  of  the 
face  rather  than  a  purple  red  cyanosis;  the  pulse  is  rapid  and  of 
poor  tension.    Mental  confusion  or  mild  delirium  with  restlessness 
and  unconsciousness  become  more  prominent  in  the  severe  cases. 

No  case  has  been  reported  in  the  armies  of  death  immediately 
upon  exposure  to  the  gas,  although  men  have  gone  through  an 
attack  of  gas  in  high  concentration  without  wearing  a  mask  at 
all  and  succumbed  in  consequence  an  hour  or  more  later. 


15 

The  action  of  phosgene  (COC12)  differs  from  that  of  chlorine  in 
certain  respects.  Upon  meeting  moist  surfaces  it  is  broken  up  and 
hydrochloric  acid  is  liberated.  It  excites  less  spasm  than  does 
chlorine  in  the  upper  respiratory  tract,  and  so  can  penetrate  to  the 
innermost  recesses  of  the  lungs,  where  it  causes  an  irritant  edema 
which  may  be  a  little  delayed  in  its  development, -like  that  caused 
by  the  acids  formed  from  nitrous  fumes,  although  the  delay  in  the 
latter  case  is  more  prolonged.  Experiments  do  not  show  that  the 
products  of  phosgene  are  absorbed  from  the  lung  and  act  as  general 
poisons  apart  from  their  local  action. 

POST-MORTEM    FINDINGS. 

Two  hours  after  exposure  to  gas. — In  a  case  of  death  by  asphyxial 
cyanosis  where  inflammatory  effusion  had  developed  with  great 
rapidity  the  lungs  were  smaller  than  normal,  heavy,  uniformly 
airless  and  purple,  so  that  each  resembled  a  big  spleen.  There  was 
no  disruptive  emphysema.  Thin  serous  fluid  ran  abundantly  from 
the  surface  when  cut  across.  Each  pleural  cavity  contained  about 
15  ounces  of  serous  effusion. 

Second  and  third  day. — There  is  no  striking  difference  between 
the  cases  which  had  shown  pallid  collapse  and  those  which  suc- 
cumbed in  extreme  cyanosis.  The  condition  of  the  heart  is  found 
to  be  variable,  but  there  is  always  evidence  in  the  viscera  of  vas- 
cular engorgement  from  failure  of  circulation.  The  lungs  never 
show  voluminous  emphysema,  and  indeed  the  earlier  the  death  the 
greater  is  the  serous  edema  in  their  substance.  On  the  second 
day  the  fluid  does  not  drip  quite  so  freely  from  the  cut  surface  as 
on  the  first,  and  toward  the  beginning  of  the  third  day  the  general 
aeration  of  the  lung  is  everywhere  greater,  while  relatively  large 
islets  of  well-aerated  and  slightly  emphysematous  lung  may  be 
present  between  areas  of  edema  or  of  collapse.  This  aerated  con- 
dition appears  at  first  in  the  lower  lobes  of  the  lungs  where  they 
are  in  contact  with  the  diaphragm,  while  edema  persists  longest 
and  is  most  profuse  in  the  upper  lobes. 

A  day  later  and  no  serous  fluid  at  all  escapes  from  the  cut  sur- 
face. At  this  date  inflammatory  complications  tend  to  appear  in 
a  surface  pleurisy,  and  areas  of  the  lung  are  found  to  be  slightly 
friable  and  entering  into  a  condition  of  broncho-pneumonia. 

It  may  be  that  cases  of  extensive  and  overwhelming  edema 
succumb  at  once,  while  those  in  which  on  the  second  or  third  day 
larger  islets  of  aerated  lung  alternating  with  edematous  patches 
are  seen,  had  from  the  beginning  been  in  that  state,  so  that  they 


16 

succumbed  later  than  the  completely  edematous  group  because 
the  injury  to  the  lung  was  less.  But  the  general  evidence  favors 
a  more  hopeful  view,  namely,  that  the  edema  fluid  is  rapidly 
absorbed  from  the  second  day  onward,  and  that  the  later  post 
mortems  illustrate  the  stages  in  this  recovery.  The  chief  fact  in 
support  of  this  view  is  that  patients  who  had  been  deeply  cyan- 
osed  at  first,  with  the  usual  signs  of  extensive  pulmonary  edema, 
and  so  asphyxiated  as  to  be  unconscious  for  a  couple  of  days,  may 
yet  recover  so  completely  that  eight  or  nine  days  after  exposure 
to  gas  it  is  difficult  to  discover  any  physical  signs  of  edema  in  the 
lung. 

SYMPTOMS. 

Onset. — Upon  exposure  to  chlorine  alone,  a  man  feels  immediate 
respiratory  distress.  He  coughs  violently  and  speech  is  made  im- 
possible by  his  spluttering  gasps.  With  the  later  forms  of  drift 
gas,  the  onset  is  slightly  altered.  There  is  some  lachrymation. 
The  throat  feels  gripped  and  the  chest  tight.  Breathing  is  difficult 
but  not  impossible.  Coughing  develops  a  quarter  of  an  hour  or 
more  later.  Nausea  and  vomiting  appear  quickly,  so  that  a  man 
who  was  slow  in  getting  protection  may  vomit  inside  his  gas  mask. 
Headache  and  throbbing  sensations  in  the  body  are  experienced. 

Development. — Coughing  and  retching  increase.  The  respiration 
becomes  very  hurried  and  labored,  though  shallow.  The  patient's 
face  assumes  a  cyanotic  hue;  he  may  lose  muscular  power  and  con- 
sciousness and  die  in  an  hour  or  two.  Those  who  survive  longer 
show  the  following  features: 

Headache,  pain  behind  the  sternum  and  in  the  epigastrium. 
Extreme  restlessness  and  anxiety,  or  a  semicoma  with  a  mutter- 
ing delirium,  from  which  as  a  rule  they  can  be  roused  to  answer 
questions.  Varying  cough,  sometimes  slight,  sometimes  reiterant 
with  a  croupous  rattling  from  exudate  in  the  trachea.  There  is 
practically  no  laryngitis.  A  cyanotic  blueness  in  the  lips  and  ears, 
which  may  accompany  a  flushed  lividity  of  the  face  or  the  grayish- 
yellow  pallor  of  collapse.  Extremely  rapid  respiration,  from  40  up 
to  even  80  a  minute,  of  a  shallow  type  on  a  distended  chest,  and  often 
marked  by  a  jerking  grunt  of  expiration.  A  pulse  of  about  100, 
which  may  rise  to  a  higher  rate  and  fall  to  a  very  low  pressure  in 
the  gray  examples  of  collapse.  The  skin  is  dry,  and  either  hot  or 
cold  in  correspondence  with  the  state  of  collapse.  Expectoration 
may  be  very  slight,  though  in  others  there  soon  develops  an 
abundant  discharge  of  thin  watery  fluid,  often  streaked  with  blood, 
which  simply  flows  from  the  mouth  as  the  dying  patient  loses  power 


17 

to  expel  it.  After  death,  the  foam  from  this  fluid]may  dry  to  a  white 
efflorescence  around  the  mouth.  The  percussion  note  is  slightly 
flattened  over  the  lungs  behind,  where  the  breath  sounds  are  much 
weakened,  but  otherwise  unchanged  in  quality.  Fine  rales  are 
heard  behind  and  in  the  axillae.  There  are  no  tubular  breath  sounds. 
In  front  there  may  be  extremely  little  change  beyond  harshness  in 
the  breath  sounds.  The  physical  signs  fail  altogether  to  indicate 
the  extent  to  which  the  lungs  are  damaged,  for  in  any  area  examined 
there  is  always  some  aeration  of  the  bronchioles  and  alveoli  which 
suffices  to  produce  relatively  normal  sounds  on  auscultation. 

The  color,  the  pulse,  and  the  rate  of  respiration  are  the  chief 
guides  to  prognosis. 

Progress. — Four-fifths  of  the  deaths  occur  in  the  first  24  hours. 
Very  few  succumb  after  the  third  day.  A  man,  who  at  first  seemed 
to  be  lightly  gassed,  may,  toward  the  end  of  the  first  day,  develop 
cyanosis  and  die;  but  from  the  end  of  the  second  day  onward,  there  is 
no  danger  to  be  apprehended  for  the  less  grave  cases.  On  the  second 
day  the  sputum  becomes  less  abundant,  more  viscous  and  yellow 
tinted.  The  dyspnea  persists  and  the  temperature  is  raised.  If 
complications  develop  subsequently  from  infections  of  the  raw 
respiratory  tract,  they  will  be  shown  by  persistence  of  fever,  by  a 
purulent  sputum,  and  by  signs  of  broncho-pneumonic  consolidation. 

But  as  a  rule  the  patient  recovers  rapidly  after  the  third  day,  and 
at  the  end  of  a  week  he  is  fully  convalescent.  Cough,  pain  in  the 
chest,  which  is  often  very  severe  beneath  the  rib  margins,  shortness 
of  breath,  loss  of  appetite  with  gastric  pain,  and  general  lassitude 
persist  longest  of  the  symptoms.  There  are  no  serious  after  results  to 
be  apprehended.  A  man  who  has  been  badly  gassed  requires  a  long 
rest;  but  the  majority,  if  free  from  neurasthenic  symptoms,  are  fit  for 
light  duty  in  a  very  few  weeks,  provided  that  they  are  allowed 
sufficient  rest  at  first.  The  heart  and  circulation  are  severely 
strained  by  gas  poisoning.  Convalescents  who  show  tachycardia 
must  be  carefully  watched  lest  too  heavy  physical  effort  early  in  the 
first  month  of  recovery  induces  further  strain  and  lead  to  the  condi- 
tion of  irritable  soldier's  heart,  from  which  recovery  will  be  long 
delayed. 

RARITIES. 

Brain. — In  some  cases  that  died  after  two  or  three  days  of  persistent 
cyanosis  and  unconsciousness  the  white  matter  of  the  brain  was 
found  to  be  peppered  with  tiny  petechial  hemorrhages.  These  are 
the  direct  outcome  of  the  asphyxial  state  and  have  little  clinical 


18 

significance.  Large  cerebral  hemorrhages  have,  however,  been 
noted,  occurring  on  the  first  or  second  day  in  cases  of  plethoric 
cyanosis. 

Vascular  obstruction. — Occasionally  the  peripheral  arteries  to  the 
limbs  may  become  occluded.  As  a  rule,  the  threatening  gangrene 
clears  up  in  these  cases. 

Stomach. — Petechial  hemorrhages  and  a  slight  superficial  ulcera- 
tion  are  often  seen  post  mortem  over  the  inner  surface  of  the  cardiac 
fundus.  The  stomach  has  occasionally  at  autopsy  been  found  to  be 
full  of  blood  from  an  extension  of  this  ulcerative  process,  but  only  in 
one  case  has  death  occurred  with  hematemesis.  The  gastric  derange- 
ments, which  generally  persist  during  convalescence,  are  not  of  a 
type  suggesting  the  result  of  an  ulcerative  process. 

Kidney. — Clinical  nephritis  is  rare,  and  its  occurrence  may  in  each 
case  have  been  a  chance  coincidence. 

TREATMENT. 
GENERAL  CONSIDERATIONS. 

REST  IS  THE  MOST  IMPORTANT  POINT  OF  ALL  IN  THE  GENERAL 
TREATMENT  OF  GAS  CASUALTIES. 

Men,  and  especially  officers,  should  be  warned  beforehand  that 
if  lightly  gassed  they  must  refrain  from  moving  about  or  shouting 
out  orders.  Physical  strain  after  gassing  may  easily  involve  the 
loss  of  a  life  that  might  otherwise  have  been  restored  to  the  fighting 
line  in  a  short  time.  The  principle  of  attaining  complete  rest  as 
soon  as  possible  underlies  the  detailed  advice  for  dealing  with  gas 
casualties  that  is  given  below,  and  is  the  reason  for  their  detention 
at  the  casualty  clearing  stations.  All  kit  that  hinders  the  play  of 
the  respiratory  muscles,  especially  belts  and  suspenders,  should  be 
undone.  Sleep  brings  improvement,  and  restless  excited  cases 
should  be  quieted  by  morphia.  It  is  important  that  arrangements 
should  be  planned  beforehand  at  each  casualty  clearing  station  so 
that  even  a  large  number  of  gas  casualties  can  be  handled  with  such 
discipline  and  control  as  will  at  once  introduce  a  sense  of  order  and 
quietude,  and  by  separating  those  who  are  more  dangerously  ill  from 
the  remainder,  enable  the  less  severe  cases  to  get  to  sleep  at  once. 

Next  in  importance  to  rest  comes  the  use  of  oxygen,  protection 
from  cold,  special  stimulants  or  drugs,  venesection,  and  methods  for 
removing  serous  exudate  from  the  lungs. 

Bronchial  spasm  does  not  seem  to  be  a  serious  danger  with  the 
present  form  of  cloud  gas.  Life  or  death  is  decided  by  the  degree 


19 

of  pulmonary  edema  and  asphyxia  with  circulatory  failure.  The 
edema  fluid  tends  to  be  absorbed  quickly,  and  if  the  patient  can 
be  carried  alive  through  the  first  two  days,  he  should  recover. 
Precautions  in  the  meantime  need  to  be  taken  to  lessen  the  chance 
that  secondary  respiratory  infections  may  develop  as  a  later  com- 
plication. 

Oxygen,  if  rightly  administered,  will  generally  lessen  cyanosis, 
and  therefore  improve  the  patient's  chance  of  life.  But  the  lung 
surface  available  for  absorption  is  so  small  that  the  oxygen  must 
be  given  in  high  concentration.  The  simple  admixture  with  air 
obtained  by  open  flow  from  a  funnel  or  a  tube  placed  in  the 
patient's  mouth  is  useless,  and  since  it  wastes  valuable  oxygen  it 
should  be  forbidden.  Given  as  the  pure  gas  from  a  bag  with  a 
valved  face  mask,  as  described  in  Treatment  at  Casualty  Clearing 
Stations  (see  p.  22),  say  for  3  or  4  minutes  every  quarter  of  an  hour, 
an  oxygen  cylinder  of  20  feet  capacity  will  last  about  4  hours.  By 
this  means  life  can  undoubtedly  be  saved  in  some  of  the  apparently 
desperate  cases.  The  administration  must  be  continued  night  and 
day,  so  as  to  hold  cyanosis  in  check.  The  consumption  of  oxygen 
by  this  method  is  so  large  that  all  care  must  be  taken  to  economize 
cylinders,  the  provision  of  which,  under  active  service  conditions 
is  necessarily  limited  by  considerations  of  transport.  Many  casual- 
ties are  so  severely  poisoned  that  their  condition  is  seen  in  the  first 
few  hours  to  be  hopeless.  Some  selection  of  the  cases  for  oxygen 
treatment  must  therefore  generally  be  made,  and  it  is  especially 
with  the  intermediate  group  who  are  surviving  into  the  second  day 
that  oxygen  has  the  best  chance  of  acting  with  ultimate  advantage. 
It  is  quite  unnecessary  to  use  it  for  relatively  mild  cases.  Deep 
cyanosis,  whether  of  the  congestive  or  pallid  type,  is  the  indication 
of  need,  and  the  lividity  can  always  almost  be  lessened  if  the  face- 
mask  is  properly  applied. 

The  subcutaneous  injection  of  oxygen  is  useless. 

Warmth  is  needed  in  many  of  the  severe  cases,  especially  at  the 
outset  when  they  are  collapsed  and  their  skin  is  cold.  To  attain 
this,  it  may  even  be  necessary  to  transfer  them  temporarily  indoors. 
Otherwise  the  fullest  supply  of  fresh  air  is  needed  for  all  cases. 
When  outside,  care  should  be  taken  to  protect  against  chill,  which 
might  lead  to  a  subsequent  broncho-pneumonia. 

Special  stimulants  and  drugs. — Ammonia  is  very  useful  as  an  inha- 
lation from  the  small  ampoules  supplied.  It  is  necessary  to  warn 
orderlies  that  these  ampoules  are  to  be  held  at  some  distance  from 
the  patient's  mouth,  and  that  their  use  should  not  be  persisted  in 


20 

where  they  seem  to  aggravate  the  difficulty  of  breathing.  The 
action  is  more  as  a  stimulant  than  in  chemical  antagonism  to  the 
chlorine. 

Brandy  and  water  is  a  good  restorative  when  given  in  small  sips. 
Cases  of  gray  collapse  with  a  rapid  pulse  of  poor  tension  do  not 
react  well  to  stimulant  drugs  and  are  almost  hopeless  when  they 
develop  this  condition  in  the  first  day.  Pituitrin,  0.5  cc.  hypo- 
dermically  every  three  hours,  gives  some  aid  to  a  failing  heart.  The 
benefit  of  digitalin  and  strychnine  is  more  doubtful. 

Venesection  gives  real  relief  to  men  with  deep  cyanosis  and  a 
full  pulse.  The  headache  is  lessened,  the  breathing  feels  easier,  and 
the  patient  may  soon  fall  into  a  sleep  that  conserves  his  strength. 
It  appears  to  be  harmful  in  collapsed  cases  with  a  poor  pulse,  and  it 
should  not  be  postponed  until  the  patient  passes  into  this  dangerous 
state. 

Methods  for  aiding  the  discharge  ofexudatefrom  the  lungs.—  (1)  Emetics 
have  been  given  at  various  times  in  the  hope  that  the  lungs  would 
be  partly  emptied  in  the  act  of  vomiting.  The  effort  is  very  ex- 
hausting and  the  results  do  not  justify  the  treatment  in  late  cases. 
But  in  the  first  few  hours,  before  the  patient  is  gravely  ill,  vomiting 
is  probably  good  and  retching  may  be  encouraged  by  simple  means. 
Later,  it  is  better  to  try  and  allay  gastric  pain  or  retching  by  the 
use  of  drinks  with  sodium  bicarbonate.  Beef  tea  is  not  to  be  recom- 
mended in  view  of  the  possibility  of  slight  gastric  ulceration. 

(2)  In  the  first  day,  if  there  is  much  fluid  expectoration,  good 
results  may  be  obtained  by  postural  treatment,  such  as  by  turning 
the  head  of  the  patient  sideways  and  then  raising  the  foot  end  of 
the  stretcher  two  or  three  feet,  or  even  higher,  for  a  few  minutes 
at  a  time. 

(3)  Schafer's   artificial   respiration   has   occasionally   proved    of 
service  in  expelling  fluid  from  the  chest,  but  it  is  necessary  to  watch 
its  effect  on  the  patient  very  closely  lest  disaster  ensue. 

(4)  Expectorants  in  large  doses,  such  as  10  or  15  grains  of  ammo- 
nium carbonate,  are  probably  harmful  at  the  beginning,  for  they 
will  cause  nausea  and  an  irritant  cough  which  will  interfere  with 
sleep  and  may  augment  the  tendency  to  disruptive  emphysema  of 
the  lungs.    Patients  who  are  not  seriously  ill  should  be  given  a 
simple  mixture  such  as  amm.  carb.  gr.  v  and  vin.  ipecac,  m.  x.  6 
hourly  on  the  second  day.     Later  treatment  might  comprise  ordi- 
nary medicinal  measures  such  as  potassium  iodide,  atropine,  steam 
tents  with  tincture  benzoin  compound,  etc.,  for  symptoms  as  they 
arise. 


21 

REGULATIONS  FOB  TREATMENT  OF  GASSED  CASES. 
TREATMENT  BY  REGIMENTAL  MEDICAL  OFFICERS. 

1.  All  ranks  should  be  warned  of  the  need  for  seeing  that  the 
gas  masks  of  wounded  men  are  kept  properly  in  position  until 
the  danger  from  gas  has  passed  away,  and  also  of  the  importance 
to  lightlj-  gassed  cases  of  remaining  absolutely  quiet. 

While  the  gas  cloud  is  concentrated,  all  ranks  should  refrain  as 
far  as  possible  from  movement,  so  that  they  may  breathe  slowly 
and  keep  the  current  of  air  through  the  gas  mask  at  a  low  velocity. 

2.  After  the  order  has  been  given  for  removal  of  masks,  ammonia 
inhalations  from  the  capsules  should  be  given  by  stretcher  bearers 
to  all  gassed  men  with  difficulty  in  breathing,  but  their  use  should 
not  be  persisted  with  in  those  special  cases  where  the  ammonia 
seems  to  increase  the  discomfort  of  the  patient. 

3.  Clothing  over  the  chest  should  be  loosened,  the  suspenders  and 
belt  undone  in  front  and  equipment  removed. 

4.  Vomiting  at  first  is  beneficial  and  it  may  be  encouraged  by 
drinks  of  tepid  water,  either  alone  or  with  salt  (1  tablespoonful  to 
half  a  pint  or  more  of  water),  and  the  back  of  the  throat  should  be 
tickled  shortly  after  the  drink  has  been  taken. 

5.  Experience  has  shown  that  atropine  is  of  no  use  in  the  early 
stages  ot  gas  poisoning. 

6.  All  gas  casualties  must  be  evacuated  as  soon  as  possible  to 
dressing  stations.    All  except  the  lightest  cases  should,  as  far  as 
possible,  be  evacuated  lying  down,  and  walking  cases  should  be 
warned  to  seek  assistance  in  going  back  along  the  trenches  so  as 
to  avoid  physical  effort  as  much  as  possible.     Special  attention 
should  be  paid  to  men  who  complain  of  feeling  collapsed,  though 
they  show  no  manifest  features  of  having  been  gassed,  since  these 
may  develop  later  the  serious  form  of  delayed  poisoning. 

Rest  is  the  one  point  that  is  essential  from  beginning  to  end  of 
the  treatment  of  gas  casualties.  Gassed  men  should  not  be  allowed 
to  carry  their  own  equipment  back  from  the  trenches.  It  is  sug- 
gested that  arrangements  for  the  disposal  of  kit  should  be  made 
regimentally  in  advance. 

TREATMENT   IN   DRESSING    STATIONS. 

1.  Casualties  should  be  kept  lying  down  in  the  open  air,  so  far 
as  weather  permits.  Suspenders  must  be  undone  and  clothing  over 
the  chest  loosened,  so  as  to  give  freedom  for  breathing. 


22 

2.  Ammonia  inhalations  should  be  given.     Experience  has  shown 
that  atropine  injections  are  of  very  doubtful  value. 

3.  If  the  patient  still  feels  inclined  to  vomit,  he  may  be  given 
tepid  drafts  of  salt  and  water,  and  the  back  of  the  throat  tickled. 

4.  Eestless  cases,  if  fully  conscious,  may  be  given  one  quietening 
injection  of  one-fourth  grain  morphia.    The  time  of  injection  and 
the  dose  must  be  recorded  on  the  diagnosis  tag. 

5.  Severe  cases  fall  into  two  groups:  The  "collapsed"  with  a 
poor  pulse  and  leaden  gray  tint,  and  the  "cyanotic"  or  "blue" 
with  a  full  pulse  and  general  asphyxial  lividity. 

6.  Collapsed  cases  may  be  retained  at  the  dressing  station  for  a 
short  time,  and  their  state  of  collapse  combated  by  stimulants 
such  as  external  warmth,  hot  drinks,  brandy,  pituitary  extract,  or 
other  drugs.     If  there  is  much  fluid  flowing  up  through  the  mouth, 
the  feet  of  the  stretcher  should  be  raised  to  a  height  of  about  4  feet 
and  the  patient's  head  turned  slightly  sideways.    This  position 
should  not  be  maintained  for  more  than  a  few  minutes  and  it  should 
be  abandoned  if  it  aggravates  the  cyanosis  or  fails  to  increase  the 
discharge  of  fluid. 

7.  Blue  cases  of  severe  cyanosis  require  continuous  treatment 
with  oxygen  in  high  concentration.     They  should  therefore  be 
evacuated  as  soon  as  possible  to  the  nearest  casualty  clearing  station 
or  field  hospital,  unless  special  apparatus  for  their  treatment  is  avail- 
able at  the  dressing  station.     If  there  is  unavoidable  delay  before 
transference  the  treatment  recommended  at  the  casualty  clearing 
station,  paragraphs  7  and  8,  should  be  tried. 

8.  All  cases  except  the  mildest  should  be  evacuated  lying  down, 
and  the  severe  cases,  with  the  exception  of  those  of  grave  collapse, 
should  be  transferred  first  of  all. 

TREATMENT  AT  FIELD  HOSPITALS  AND  CASUALTY  CLEARING  STATIONS. 

1.  Serious  cases  should  at  once  be  separated  from  the  slight,  so 
that  the  latter  may  lose  their  anxiety  and  get  to  sleep. 

2.  Ammonia  inhalations  may  be  useful  on  admission  at  any  time 
up  to  24  hours  after  exposure  to  gas. 

3.  Open  air  treatment  is  best,  if  the  weather  permits,  and  com- 
plete rest  is  essential  for  the  first  two  days.    The  clothing  and 
suspenders  should  be  loosened,  and  the  worst  cases  should  be  un- 
dressed and  put  to  bed  wherever  this  is  possible. 

No  patient  should  be  allowed  to  leave  his  bed  or  stretcher  for 
any  purpose  whatsoever. 


23 

4.  Restless  cases,  if  not  unconscious,  may  be  quieted  by  one 
injection  of  one-quarter  grain  morphia. 

5.  Collapsed  cases  should  be  treated  with  warmth  and  stimulants 
as  described  in  dressing  station  6,  and  oxygen  should  be  used  in 
addition.    Atropine  is  harmful  to  these  patients. 

6.  Attention  should  be  paid  to  the  posture  of  unconscious  cases, 
both  to  aid  discharge  of  any  fluid  that  may  be  escaping  from  the 
lungs  and  to  avoid  injury  to  nerves  or  skin  by  pressure,  e.  g.,  from 
a  clasp  knife  or  the  edge  of  the  stretcher,  if  the  patient  is  not 
undressed  and  in  bed. 

7.  Cyanosis  can  be  lessened  by  the  administration  of  oxygen  in 
high  concentration.       For  this  purpose  the  flow  from  a  simple 
funnel  or  a  tube  in  the  mouth  is  inadequate  and  wasteful  of  the 
gas.    An  apparatus  should  be  used  with  a  valved  face  mask,  such 
as  that  for  nitrous  oxide  anesthesia,  the  valves  being  so  set  that 
the  patient  breathes  in  oxygen  from  the  bag  and  breathes  out  into 
the  open  air.    The  treatment  should  be  continued  hour  after  hour 
with  brief  intervals  until  the  edema  of  the  lungs  clears  up.    Cases 
may  recover  after  being  cyanosed  and  unconscious  for  two  days. 

8.  Venesection,  performed  slowly,  to  the  amount  of  15  or  20 
ounces  may  be  of  use  to  "blue"  cases  if  practiced  early  and  before 
the  pulse  begins  to  fall. 

9.  Expectorants. — Drugs  such  as  ammonium  carbonate  and  vinum 
ipecac  are  recommended  for  use  in   expectorant  doses  from   the 
second  day  onward. 

10.  The  diet  should  be  light  and  simple.    Measures  should  be 
taken  to  open  the  bowels. 

11.  As  far  as  circumstances  permit,  no  case  should  be  evacuated 
to  the  line  of  communication  until  definite  cyanosis  or  serious  symp- 
toms have  disappeared.    A  note  should  be  sent  down  with  those 
cases  which  have  passed  through  a  condition  of  gravity,  so  as  to  guide 
the  medical  officer  on  the  line  of  communication  as  to  the  future 
treatment  of  the  case. 

LINES   OF  COMMUNICATION. 

The  methods  of  treatment  advised  at  casualty  clearing  stations 
are  applicable  for  use  in  hospitals  on  the  line  of  communication 
when  circumstances  necessitate  the  early  evacuation  of  cases. 

A  very  large  proportion  of  the  casualties  sent  to  the  base  as  "gassed 
cases  "  are  likely  to  become  fit  for  duty  after  a  short  rest.  Wastage 
by  transfer  to  home  territory  is  to  be  avoided,  and  medical  officers 
should  exercise  the  greatest  care  in  selecting  cases  for  evacuation 
to  home  hospitals. 


24 

As  a  rule,  only  cases  in  which  there  was  a  clear  history  of  grave 
cyanosis  or  collapse,  or  in  which  secondary  infections  of  the  respi- 
ratory tract  have  developed,  should  be  sent  farther  than  the  base. 
It  may  be  taken  for  granted  that  all  casualties  which  had  been 
detained  in  a  casualty  clearing  station  for  five  days  were  of  a  serious 
nature,  whatever  their  condition  on  arrival  at  the  base  hospital. 

Rest  stations. — Rest,  with  the  possibility  of  lying  down  on  a  bed 
at  any  time  of  the  day,  must  be  provided  during  the  first  two  or 
three  weeks  for  all  cases  except  the  very  mildest.  Arrangements 
should,  when  possible,  be  made  at  the  base  to  give  accommodation, 
if  the  patients  can  not  be  retained  in  the  main  hospitals,  for  an  easy 
life  of  this  nature  which  is  not  permitted  in  the  usual  routine  of 
convalescent  depots. 

^Convalescent  depots. — Gas  casualties,  who  show  neurasthenic  or 
cardio- vascular  weakness  after  three  weeks'  treatment  at  the  depot, 
should  be  transferred  to  home  hospitals. 

INDEX  TO  DRUGS  WHICH  HAVE  AT  VARIOUS  TIMES  BEEN   USED. 

Ammonia. — The  benefit  of  occasional  inhalations  of  ammonia 
during  the  fir?t  day  is  universally  admitted.  Spiritus  ammon. 
aromat.  in  4  cc.  doses  with  plenty  of  water  is  useful  as  a  direct 
stimulant,  but  it  does  not  ease  breathing  in  the  same  way  as  does 
vapor. 

Ammonium  carbonate. — In  large  doses  of  gr.  xv  as  an  emetic  has 
proved  harmful  and  never  done  good  in  the  early  stages.  As  an 
expectorant  it  should  only  be  used  in  small  doses  of  gr.  v. 

Apomorphine. — In  hypodermic  doses  of  gr.  ^  has  been  recom- 
mended as  an  emetic.  The  vomiting  often  fails,  the  drug  is  depres- 
sant, and  its  use  had  never  proved  to  be  of  the  least  value. 

Atropine  has  been  supposed  to  be  useful  in  the  early  stages  of 
poisoning,  both  to  relieve  bronchial  spasm  and  to  check  the  secretion 
of  edema  fluid.  The  drug  has  been  extensively  tried,  both  in  the 
French  and  British  medical  services,  and  no  conclusive  evidence  of 
such  benefit  has  been  found.  On  the  other  hand,  atropine  does  tend 
to  accelerate  the  heart  beat,  and  a  result  of  this  nature  is  an  actual 
disadvantage  to  an  asphyxiated  patient.  Its  use  in  the  first  two  or 
three  days  should  therefore  be  discontinued. 

Camphor  in  conjunction  with  ether  forms  a  useful  stimulant  in 
cases  of  collapse.  Th3  Japanese  in  the  Russian  War  used  as  a  general 
stimulant  a  hypodermic  injection  of  10  or  15  minims  of  camphor  1 
part,  ether  4-5  parts,  olive  oil  4  parts.  It  is  possible  that  this  might 
also  be  of  value  in  cases  of  gas  poisoning  associated  with  collapse. 


25 

Digitolin,  grain  1/100,  hypodermically,  has  so  slight  an  action  that 
it  probably  is  not  worth  using  in  the  two  or  three  critical  days  of 
acute  pulmonary  edema. 

Ipecacuanha  has  been  recommended  as  having  a  specific  action 
in  promoting  the  absorption  of  edema  fluid.  For  this  purpose, 
20  to  30  minims  of  the  Vinum  have  been  given  two-hourly.  Nausea 
and  emesis  are  not  aimed  at.  The  evidence  as  to  its  action  in  this 
sense  is  inconclusive,  though  it  is  useful  in  smaller  doses  as  an 
ordinary  expectorant.  The  drug  should  not  be  given  as  an  emetic, 
because  it  produces  depression. 

The  extractive,  Emetine,  has  been  tried  hypodermically  in 
repeated  doses  of  gr.  J  and  without  any  apparent  benefit  whatso- 
ever. 

Morphia  is  most  useful  as  a  sedative  and  may  be  given  even  to 
deeply  cyanosed  patients  for  extreme  restlessness.  The  dose  should 
not  be  large,  gr.  £,  followed,  if  need  be  by  gr.  |,  or  15  to  20  minims 
of  tinct.  opii. 

Phenacetin  and  Aspirin  have  been  given  to  relieve  the  headache 
caused  by  mine-gas  poisoning,  and  they  were  found  to  produce  a 
dangerous  state  of  collapse  in  these  patients.  It  is  therefore  in- 
advisable to  use  them  for  the  headache  that  follows  the  inhalation 
of  cloud  gas. 

Pituitrin  0-5  cc.  into  the  muscles  or  hypodermically  increases 
card io- vascular  tone  for  a  short  time  and  gives  aid  to  a  failing  heart. 
If  a  second  injection  is  given  15  to  20  minutes  after  the  first,  it  may 
cause  the  pressure  to  fall.  An  interval  of  three  hours  should  be 
observed  if  the  dose  is  repeated. 

Sodium  lactate  taken  by  the  mouth  every  four  hours  in  2  drachm 
doses  of  a  50  per  cent  solution  has  been  employed  with  a  view  to 
augmenting  the  alkaline  bases  of  the  blood,  fixing  some  of  the 
excess  of  carbon  dioxide,  and  thereby  tending  to  lessen  the  rate 
of  respiration.  The  main  features  of  gas  poisoning  are  not  influenced 
by  this  method  of  treatment. 

Sparteine  has  erroneously  been  supposed  to  be  a  cardiac  tonic  and 
a  useful  drug  in  the  place  of  digitalin.  Actually  it  is  a  poison  which 
slows  and  weakens  the  heartbeat. 

Strychnine,  one-thirtieth  grain,  may  be  employed  in  the  early 
stages  of  pallid  collapse. 

NITROUS  FUMES. 

Though  no  cases  of  nitrous  fumes  poisoning  have  hitherto  been 
recorded,  the  possibility  of  their  occurrence  owing  to  exposure  to 
the  fumes  of  burning  explosives  should  not  be  lost  sight  of. 


26 

The  great  danger  of  nitrous  fumes  arises  from  the  fact  that  in  the 
concentrations  usually  met  with  there  is  comparatively  little  irrita- 
tion of  the  eyes  or  upper  respiratory  passages,  and  a  man  working 
in  such  an  atmosphere  will  not  recognize  its  deadly  nature.  Air 
which  contains  enough  nitrous  fumes  to  cause  feelings  of  irritation 
in  the  nose  or  air  passages  must  be  regarded  as  very  dangerous. 
Nitrous  fumes  are  very  soluble  in  water,  and  the  gas  may  be  readily 
removed  from  the  atmosphere  by  means  of  a  water  spray,  whilst  a 
few  folds  of  a  handkerchief  or  a  towel  wetted  with  water  and  tied 
over  the  nose  and  mouth  will  give  efficient  protection  in  the  ab- 
sence of  a  mask.  The  possibility  of  the  simultaneous  occurrence  of 
carbon  monoxide  in  atmospheres  containing  nitrous  fumes  must  be 
remembered. 

Owing  to  the  delay  in  the  onset  of  serious  symptoms,  it  is  essential 
that  any  man  who  is  suspected  of  having  been  exposed  to  nitrous 
fumes  should  be  sent  to  hospital  with  as  little  delay  as  possible  and 
detained  there  for  24  hours  for  observation. 

Pathological  changes. — The  pathological  changes  found  post-mortem 
in  a  fatal  case  of  nitrous-fumes  poisoning  are  identical  with  those 
described  above  as  characteristic  of  chlorine  poisoning.  If  the  con- 
centration of  nitrous  fumes  to  which  the  case  has  been  exposed  is 
very  high,  the  blood  may  be  somewhat  chocolate  colored  owing  to 
the  formation  of  methaemoglobin. 

Symptoms. — If  the  gas  is  in  very  great  concentration,  rapid  fatal 
asphyxiation  takes  place,  but  in  the  concentrations  that  are  usually 
encountered,  the  characteristics  which  distinguish  this  from  chlorine 
poisoning  are  the  slightness  of  the  initial  symptoms  due  to  irritation 
of  the  upper  respiratory  passages  and  delay  in  the  onset  of  acute 
pulmonary  edema. 

The  typical  sequence  of  events  is — 

(1)  Slight  irritation  of  the  nose  and  throat,  feeling  of  constric- 
tion of  the  chest,  headache  and  slight  smarting  of  the  eyes  and 
coughing  while  actually  exposed  to  the  fumes. 

(2)  On  leaving  the  poisonous  atmosphere  a  latent  period  during 
which  the  case  may,  and  usually  does,  feel  quite  well  and  has  no 
hesitation  in  taking  a  meal. 

(3)  The  sudden  onset  after  four  to  eight  hours  of  acute  symp- 
toms.    These  commence  with  marked  and  increasing  distress  in 
breathing,  coughing,  and  often  severe  pain  in  the  chest.    The  cough 
is  at  first  dry,  and  auscultation  may  reveal  no  moist  sounds.    This 
condition  is  speedily  followed  by  the  urgent  signs  of  acute  pul- 
monary edema  which  have  been  already  detailed  under  chlorine 
poisoning  (p.  13),  and  death  may  ensue  in  a  few  hours. 


27 

Treatment. — When  once  pulmonary  edema  has  developed,  the 
treatment  should  follow  the  lines  already  laid  down  for  chlorine 
poisoning  (p.  18).  The  experience  of  medical  officers  attached 
to  mines  on  the  Band,  where  nitrous  fumes  are  frequently  met 
with  during  blasting  operations,  points  to  the  value  of  inducing 
emesis  as  soon  after  exposure  to  the  fumes  as  possible,  followed  by 
a  dose  of  such  a  stimulant  as  spir.  ammon.  aromat.  A  case  of  nitrous- 
iumes  poisoning  should  be  under  medical  observation  at  the  time 
when  acute  pulmonary  edema  is  likely  to  develop  and  a  venesection 
of  from  15  to  20  ounces  should  be  made  as  soon  as  there  is  the  slightest 
sign  of  its  onset.  Venesection  must  not  be  delayed  until  the  patient's 
condition  is  grave  and  the  stage  of  lividity  has  been  reached,  or  it 
will  be  useless. 

LACHRYMATORS. 

Hitherto,  no  serious  cases  of  poisoning  have  occurred  as  the  result 
of  exposure  to  the  effects  of  shells  containing  substances  employed 
merely  on  account  of  their  lachrymatory  properties. 

The  immediate  effect  of  a  trace  of  the  vapor  of  such  a  lachrymator 
as  benzyl  bromide  in  the  air  is  to  cause  profuse  watering  of  the 
eyes,  accompanied  by  smarting.  If  the  concentration  is  somewhat 
greater,  the  smarting  and  pain  in  the  eyes  may  become  intolerable, 
so  that  it  is  impossible  to  keep  the  eyes  open.  The  smarting  and 
watering  of  the  eyes  will  be  quite  sufficient  to  put  a  man  completely 
out  of  action,  because  he  is  incapable  of  seeing,  but  protection  of  the 
eyes  is  easily  obtained  by  the  use  of  goggles. 

With  increasing  concentrations  of  the  vapor,  other  effects  show 
themselves.  The  vapor  is  irritant  to  the  lungs  and  upper  respiratory 
passages  and  this  leads  to  a  burning  sensation  in  the  throat  and 
coughing.  Nausea  is  often  present  and  not  infrequently  leads  to 
vomiting,  accompanied,  it  may  be,  by  pain  in  the  epigastrium.  If 
it  is  impossible  to  withdraw  from  exposure  to  the  fumes,  slight  con- 
fusion  of  mind  and  torpor  may  show  themselves. 

Under  ordinary  conditions  the  symptoms  do  not  develop  further, 
and  though  the  case  may  become  somewhat  collapsed  as  a  result  of 
the  vomiting  and  general  discomfort,  this  is  only  temporary,  and 
within  an  hour  or  two  after  getting  into  air  free  from  the  lachry- 
mator there  may  be  very  little  amiss  with  the  man.  The  nausea  and 
irritation  of  the  throat  soon  pass  off,  though  the  eyes  may  remain 
sore  for  some  little  time,  and  even  after  the  lapse  of  12  hours  redness 
of  the  eyelids  and  slight  injection  of  the  conjunctiva  may  still  be 
evident.  There  are  no  subsequent  toxic  effects  and  the  case  will  be 
fit  for  duty  as  soon  as  the  primary  effects  have  passed  off. 


28 

It  must  not  be  forgotten  that  some  of  the  acute  lung  irritants  are 
also  extremely  powerful  lachrymators,  and  that  such  substances 
may  be  used  with  a  view  to  securing  a  double  effect,  viz,  immediate 
blinding  and  simultaneous  intense  toxic  effect  on  the  lungs.  In 
order  to  secure  such  an  effect  it  is  essential  that  the  substance  used 
shall  be  gaseous  or  shall  vaporize  with  sufficient  rapidity  to  attain  a 
high  enough  concentration  in  the  air  to  produce  these  intense  toxic 
effects.  Lachrymators  such  as  benzyl  bromide,  which  are  liquid 
at  ordinary  temperatures,  vaporize  too  slowly  to  produce  such  a 
concentration,  and  the  symptoms  caused  by  a  lachrymator  of  this 
type,  therefore,  very  rarely  attain  a  degree  of  severity  greater  than 
those  described  above  in  detail. 

The  smell  of  benzyl  bromide  when  in  great  dilution  suggests  the 
flavor  of  mustard  and  cress.  Lachrymators  as  a  rule  have  aromatic, 
pungent  odors. 

HYDROCYANIC  ACID. 

When  in  sufficient  concentration  this  gas  acts  as  a  very  rapid  and 
sometimes  almost  instantaneous  poison,  affecting  directly  the  central 
nervous  system. 

Symptoms. — These  follow  one  another  in  rapid  sequence:  Giddi- 
ness, confusion,  headache,  indistinct  sight,  palpitation  and  pain  in 
the  chest  and  over  the  heart.  Labored  respiration.  Unconscious- 
ness, convulsions,  failure  of  the  respiration  and  finally  of  the  heart. 
In  la^ge  doses,  immediate  unconsciousness,  dilatation  of  the  pupils, 
a  few  gasping  respirations,  and  death  with  or  without  convulsions. 

The  gas  paralyzes  the  respiratory  center  very  quickly,  and  with 
small  fatal  percentages  the  heart  may  continue  to  beat  for  a  brief 
time  after  the  respiration  has  ceased.  With  larger  concentrations 
the  heart  may  be  stopped  almost  at  once  by  the  direct  action  of  the 
poison. 

When  death  is  caused  by  inhalation  of  hydrocyanic-acid  gas,  it  is 
unlikely  that  the  smell  of  the  gas  will  be  detected  at  autopsy,  as 
may  be  the  case  when  poisoning  is  due  to  the  ingestion  by  the 
mouth  of  a  large  dose  of  prussic  acid. 

Treatment. — Immediate  treatment  is  the  only  measure  of  any 
avail  if  a  man  falls  unconscious  from  hydrocyanic-acid  poisoning. 
The  case  must  be  at  once  dragged  into  fresh  air,  and  if  the  respiration 
has  stopped,  or  is  very  weak  and  gasping,  artificial  respiration  must 
be  instantly  applied  by  Schafer's  method.  It  is  possible  by  this 
means  to  resuscitate  a  case,  and  if  this  is  so  recovery  will  be  perfect. 
Cold  water  may  be  splashed  oh  the  face  and  chest  and  friction 
applied  to  the  limbs,  but  time  should  not  be  wasted  on  these  meas- 


29 

ures  before  commencing  artificial  respiration.  The  same  immediate 
treatment  holds  good  for  any  other  gas  that  causes  rapid  unconscious- 
ness from  its  effects  on  the  central  nervous  system. 

CAJIBON   MONOXIDE. 

The  great  danger  of  carbon  monoxide  arises  from  the  fact  that  the 
gas  is  colorless,  odorless,  and  nonirritant,  and  that  the  onset  of 
symptoms  is  so  insidious  that  very  often  the  first  warning  that  a  man 
may  receive  is  failure  in  the  power  of  his  limbs  which  will  prevent 
him  from  retreating  into  safety.  Neither  the  box  respirator  nor 
other  masks  give  protection  against  carbon  monoxide;  protection 
can  only  be  attained  by  the  use  of  special  oxygen  breathing 
apparatus. 

Pathological  changes. — At  the  autopsy,  the  blood  may  be  red  in 
color  instead  of  dark  if  there  is  a  considerable  degree  of  saturation 
of  the  hemoglobin  with  carbon  monoxide.  If  the  case  has  continued 
to  breathe  for  some  time  after  reaching  an  atmosphere  free  from 
carbon  monoxide,  this  gas  will  have  been  partly  or  entirely  displaced 
from  the  hemoglobin  and  the  blood  after  death  will  have  its  normal 
color. 

The  simplest  method  of  detecting  the  presence  of  carbon  mo- 
noxide in  blood  is  to  compare  the  color  of  a  dilute  solution  of  the  sus- 
pected blood  with  a  similar  solution  of  normal  blood.  Take  a  drop  or 
two  of  blood  from  the  finger  of  a  normal  person  and  dilute  it  in  a  test 
tube  very  considerably  with  water  (a  one-half  of  1  per  cent  solution  is  a 
convenient  strength),  so  that  when  examined  by  transmitted  daylight 
the  color  of  this  solution  is  a  reddish-yellow.  Then  take  a  drop  or 
two  of  the  suspected  blood  and  dilute  it  similarly  with  water,  so  that 
the  depth  of  color  of  the  solution  is  the  same  as  that  of  the  solution  of 
normal  blood  when  both  are  viewed  by  transmitted  light.  On  exam- 
ining the  quality  of  the  color  it  will  be  found  that  the  solution  made 
with  the  suspected  blood,  if  it  contains  carbon  monoxide  hemoglobin, 
is  definitely  pinker  than  that  made  with  the  normal  blood,  though 
it  will  not  have  the  full  pink  tint  of  the  same  normal  blood  solution 
if  the  latter  be  shaken  with  coal  gas  so  as  to  saturate  it  quite  com- 
pletely with  carbon  monoxide. 

The  lungs  show  no  abnormal  changes  in  cases  of  rapid  death. 
Small  punctate  hemorrhages  may  be  found  in  the  white  matter  of 
the  brain  and  sometimes  ecchymoses  in  the  meninges  if  the  case 
has  been  exposed  to  a  concentration  of  carbon  monoxide  sufficient 
to  cause  prolonged  unconsciousness. 


30 

Symptoms. — Except  with  very  massive  doses,  when  loss  of  con- 
sciousness is  very  rapid,  the  symptoms  develop  very  gradually,  as 
the  gas  is  only  absorbed  slowly.  If  a  man  is  at  rest  in  a  concen- 
tration of  the  gas  of  1  part  in  1,000  it  will  take  about  two  hours 
before  definite  giddiness  appears  and  he  will  not  be  definitely  dis- 
abled until  the  lapse  of  two  and  one-half  hours.  The  rate  of  ab- 
sorption of  the  gas  is  much  quickened  when  the  breathing  is  deep- 
ened during  muscular  exercise  and  the  exercise  also  leads  to  great 
accentuation  of  the  symptoms.  With  a  concentration  of  2  parts  in 
1,000  a  man  will  be  seriously  affected  in  half  an  hour  if  he  is  per- 
forming a  moderate  amount  of  muscular  work,  and  this  concentra- 
tion may  prove  fatal  with  prolonged  exposure. 

Small  animals  are  far  more  quickly  affected  by  carbon  monoxide 
than  man  is,  owing  to  the  natural  great  ventilation  of  their  lungs 
and  the  rapidity  of  their  circulation.  A  mouse  or  a  canary  will 
show  definite  symptoms  of  carbon  monoxide  poisoning  in  a  tenth  of 
the  time  that  a  man  will.  If  small  animals  are  used  to  give  an 
index  of  the  presence  of  carbon  monoxide  in  a  suspected  atmos- 
phere, it  must  be  remembered  that  though  they  show  symptoms 
long  before  a  man  feels  any  effects,  the  man  will  in  the  end  be 
reduced  to  the  same  condition  as  the  animal,  and  he  ought  there- 
fore to  leave  the  dangerous  atmosphere  directly  the  animal  shows 
signs  of  being  affected,  unless  he  is  protected  by  special  apparatus. 

The  first  sign  that  tells  a  man  that  something  is  amiss  is  very 
frequently  a  feeling  of  loss  of  power  in  the  limbs.  Giddiness, 
slight  confusion  of  mind,  and  breathlessness  and  palpitation  on  the 
least  exertion  also  show  themselves.  The  confusion  of  mind  and 
loss  of  power  in  the  legs  frequently  preclude  a  man  from  with- 
drawing from  danger,  even  though  he  is  dimly  aware  that  safety  is 
only  a  few  yards  distant.  The  failure  of  power  in  the  limbs  and 
mental  confusion  rapidly  increase  and  the  man  may  appear  drunk, 
shouting  incoherently,  laughing,  swearing,  or  praying.  Apathy  and 
complete  helplessness  supervene,  and  failure  of  the  intellectual 
powers  gradually  passes  into  complete  unconsciousness,  which  may 
finally  terminate  in  a  painless  death. 

The  symptoms  may  remain  stationary  at  any  stage,  since  the 
degree  of  saturation  of  the  hemoglobin  with  carbon  monoxide  reaches 
a  final  end  point  which  is  determined  by  the  relative  concentra- 
tions of  the  carbon  monoxide  and  the  oxygen  which  are  simul- 
taneously trying  to  combine  with  the  hemoglobin. 

Even  in  cases  of  mild  gassing  with  carbon  monoxide,  a  severe 
headache  accompanied  by  nausea  is  very  likely  to  develop. 


31 

Treatment. — The  symptoms  detailed  above  are  due  to  the  gradual 
diminution  of  the  oxygen-carrying  power  of  the  blood  and  the 
exposure  of  all  the  organs  of  the  body  to  increasing  want  of  oxygen. 
It  is  clear  that  any  increase  in  the  oxygen  demands  of  the  body 
is  to  be  avoided,  and  any  man,  therefore,  who  shows  definite  signs 
of  gassing  should  be  carried  to  a  place  of  safety.  If  he  attempts 
to  walk  himself  he  is  quite  likely  to  fall  down  unconscious.  When 
a  moderately  gassed  case  reaches  fresh  air  he  sometimes  falls  un- 
conscious, while  other  cases  may  commence  to  shout  and  struggle, 
in  which  case  their  movements  need  to  be  controlled. 

Any  case  showing  definite  symptoms  should  be  removed  as  soon 
as  possible  to  some  place  of  safety  where  he  can  remain  at  rest  for 
an  hour  or  two  before  evacuation.  Rest  is  essential. 

As  carbon  monoxide  hemoglobin  is  a  dissociable  compound,  the 
carbon  monoxide  is  gradually  driven  out  of  its  combination  with 
hemoglobin  by  the  oxygen  of  the  air  as  soon  as  an  atmosphere  free 
from  carbon  monoxide  is  reached.  In  fresh  air  it  will  take  an 
hour  or  two  before  the  blood  is  entirely  freed  from  carbon  monoxide, 
but  the  process  can  be  rendered  five  times  as  rapid  by  giving  the 
patient  pure  oxygen  to  breathe.  It  is  important  therefore  to  begin 
the  administration  of  oxygen  by  some  efficient  method  as  soon  as 
possible  after  the  case  has  been  removed  from  the  poisonous  at- 
mosphere. A  suitable  method  has  been  described  under  chlorine 
poisoning  (p.  19)  and  the  oxygen  apparatus  that  is  kept  at  mine 
rescue  stations  is  also  most  efficient.  Administration  of  oxygen 
should  be  kept  up  as  continuously  as  possible  for  half  an  hour  to 
an  hour,  depending  on  the  severity  of  the  symptoms.  It  should  be 
remembered  that  if  a  case  can  be  kept  at  rest  for  half  an  hour  and 
oxygen  administered  immediately  after  being  removed  from  the 
poisonous  atmosphere,  he  will  be  in  far  better  condition  to  travel 
than  if  he  has  to  be  removed  to  a  more  distant  point.  If  the  breath- 
ing is  very  shallow,  administration  of  oxygen  may  be  combined  with 
artificial  respiration. 

Collapse  should  be  combated  by  external  warmth  and  by  friction 
of  the  limbs. 

In  chlorine  poisoning  the  pulmonary  edema  and  damage  to  the 
lungs  and  the  consequent  interference  with  the  gaseous  exchange 
taking  place  between  the  blood  and  the  air  in  the  lungs  persist  for 
some  time  and  may  necessitate  the  administration  of  oxygen  for 
several  days.  In  carbon  monoxide  poisoning  the  structure  of  the 
lungs  is  not  interfered  with  and  oxygen  is  administered  with  the 
deliberate  intention  of  accelerating  the  discharge  of  carbon  mon- 


32 

oxide  from  the  blood.  When  once  this  has  been  accomplished, 
i.  e.,  after  half  an  hour's  or  an  hour's  administration,  there  is  no 
need  to  continue  the  oxygen  administration,  as  the  oxygen-carrying 
power  of  the  blood  has  now  become  normal  again.  Any  symptoms 
that  persist  are  due  to  effects  that  were  produced  while  the  blood 
was  charged  with  carbon  monoxide  and  are  unlikely  to  be  influenced 
by  oxygen  administration  when  once  the  carbon  monoxide  has  been 
got  rid  of.  Further  oxygen  administration  is  therefore  required 
only  if  cyanosis  begins  to  develop  subsequently  from  secondary 
cardiac  or  respiratory  failure. 

Cases  of  carbon  monoxide  poisoning  have  been  known  to  recover, 
even  when  they  have  remained  unconscious  for  so  long  as  48  hours 
after  removal  from  the  poisonous  atmosphere.  In  cases  that  liave 
been  severely  gassed  the  possibility  of  subsequent  cardiac  dilatation 
must  not  be  lost  sight  of,  and  cases  of  severe  gassing  should  not  be 
returned  to  duty  until  confidence  is  felt  that  the  circulation  has 
recovered  from  the  strain.  As  a  result  of  damage  to  the  nervous 
system  while  the  blood  was  charged  with  carbon  monoxide,  paralysis 
of  single  muscles  or  of  groups  of  muscles,  or  different  forms  of  mental 
disturbance  are  sometimes  found  as  sequelae. 

NEED   FOR   FURTHER   INVESTIGATION. 

Knowledge  on  the  various  points  discussed  in  this  pamphlet  is 
still  far  from  being  stable.  Medical  officers  are  therefore  asked  to 
assist  by  making  further  observations  and  at  once  writing  down  notes 
on  any  of  the  following  particulars,  about  which  chance  may  enable 
them  to  supply  useful  information.  Such  notes  should  be  forwarded 
to  the  division  surgeon. 

1.  Smells  of  the  gas.    This  may  be  musty,  pungent,  aromatic 
like  lilac,  garlic,  mustard  and  cress,  bitter  almonds,  and  so  on. 

2.  The  symptoms  in  gassed  men,  especially  those  of  onset,  when 
they  are  in  any  way  remarkable  or  differ  from  those  described  for 
cloud  gas  in  this  pamphlet.    All  points  not  observed  by  the  medical 
officer  himself  should  be  subjected  to  careful  cross-examination. 

3.  The  findings  at  autopsy  of  very  early  cases  of  gas  poisoning, 
with  an  account  of  the  manner  of  death. 

4.  The  value  of  various  methods  of  treatment  of  severely  gassed 
cases,  with  control  observations  where  possible. 


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